Physician Progress Notes Not Updated to Reflect Discontinued Medications
Penalty
Summary
The facility failed to ensure that physicians' progress notes accurately reflected the current medication regimen for two residents. For one resident with polyneuropathy, the Lidocaine patch was discontinued in the physician's orders and medication administration record, but the most recent physician progress note still indicated the patch should be continued at bedtime. The care plan did not mention the medication, and nursing staff were unaware of the last administration, leading to confusion about the resident's current treatment. For another resident with a history of tremors, Benztropine Mesylate had been discontinued months prior, and there were no active orders for the medication. However, the physician's progress notes continued to state that Benztropine should be continued. The care plan did not reference the medication, and nursing staff confirmed the discrepancy between the progress notes and the actual orders, acknowledging the importance of consistency for resident care. Interviews with staff, including LVNs and the DON, revealed a lack of oversight in ensuring that physician progress notes were updated to match current orders. The DON stated that she did not review the quality or accuracy of the physician's notes, and the physician acknowledged that updates to progress notes may be missed when medication changes occur. Facility policy and OBRA regulations require that clinical records, including physician progress notes, accurately reflect the resident's current plan of care.